Nursing Home Disregards Its Residents’ Lifesaving Medical Wishes
Chris Jensen Health and Rehabilitation Center, a Duluth nursing home with 170 beds, has a history of violating regulatory measures and lacking a system for ensuring patients’ medical wishes are granted, particularly when it comes to lifesaving procedures. It has most recently been cited for neglect after state investigators found that four of its nurses failed to attempt resuscitation efforts last May on a patient who was found unresponsive and ultimately died.
The unidentified patient had a physician’s order on file for receiving treatment should the individual be found unresponsive, also known as a POLST, directing that cardiopulmonary resuscitation (CPR) be performed. Despite this order, four nurses failed to provide basic life support, according to investigators. The patient had lived at the facility for over a year and had been diagnosed with cellulitis, respiratory failure, and a bacterial skin infection.
The day of the resident’s death, the individual went through the normal morning routine as usual and laid down in bed after breakfast. Forty minutes later, a nursing assistant checked the resident’s pulse, but could not feel a heartbeat. So, the assistant ran for a nurse, who repeated the checks then summoned a second nurse.
“Neither nurse started CPR,” special investigator Peggy Boeck wrote in her report. “Two additional nurses arrived, looked at the resident’s CPR status in the chart and did not start CPR. Nurse #4 called the on-call supervisor out of concern that no one started CPR…The resident died.”
The nurses, who were all certified in CPR at the time, were interviewed by Boeck. One knew the patient had a POLST but figured it was too late to start resuscitation efforts. Another assumed the individual did not want to them to take lifesaving measures. A third nurse was “too upset to do anything, including CPR,” the investigators said. A nurse practitioner told investigators that she gave an order to not start CPR after learning that the patient was “cold, stiff and had been dead for a while.”
The Health Department investigation determined that the incident and the decision not to act, contrary to the resident’s medical wishes, posed an immediate health risk to 45 other patients who had requested CPR in similar situations. Since May, Chris Jensen Health and Rehabilitation Center has made an effort to educate all its nurses on CPR and emergency response, conducting emergency drills to verify staff is aware of its protocol, and all resident records were reviewed to ensure that each patient had a physician’s order for lifesaving treatment.
Amy Porter, executive director of the facility, said it is committed to providing quality care to all of its residents. “At all times, the health, safety, and privacy of our residents and staff are our first priority,” she said. Yet, over the past three years, health inspectors have cited the home for more than thirty violations of health, safety, and quality of life standards. In 2016, it was fined nearly $24,000 and was temporarily blocked by federal regulators from receiving new Medicare and Medicaid payments, for multiple deficiencies, including disregarding medical wishes. The latest investigation concluded July 31 after site visits on June 12-13.